Vol.1 Issue 3

Power of

revention®

The Biggest Loser Contestant

Weighs in on Life after the Show Page 2

Is BARIATRIC Surgery Right for You? Page 14

Battling Childhood

Obesity Page 20

What is “Sick Fat?” Page 17

Power of Prevention is a public health awareness initiative dedicated to giving patients the resources they need to live healthier lives. For more than five years, Power of Prevention has been educating patients about a variety of endocrine conditions, including diabetes, thyroid dysfunction and obesity.

JULIE HADDEN: Fat Chance

Page 2

Ta b l e o f C o n t e n t s 1 What is Obesity?

14 Is Bariatric or

Metabolic Surgery Right for Me?

An introduction to what you can do to change your life

5 DXA: A New Way

Examining different types of bariatric surgery and learning if bariatric surgery is right for you

to Monitor Weight Loss Discover how a diagnostic exam used to test your bones for osteoporosis can be used to evaluate your body composition

6 What Are the

Complications of Obesity?

Learn how overweight or obesity can affect you physically, mentally and emotionally

8 Medical Nutrition Therapy Exploring the dos and don’ts of eating healthy and giving you tips for losing those extra pounds

11 Newfound Simplicity Meet Kathy Gallagher and learn about her struggles to lose weight

12 Weight Loss Medications

16 Learning to Live

20 Battling Childhood

Obesity: A Treatment Plan Discussing the real-life consequences of childhood obesity and how to treat the problem

22 What is Power of Prevention doing in Schools?

Meet Yehuda Greenwald and learn how bariatric surgery changed his life

A look at how the Power of Prevention program is helping students in one Florida school

17 The Skinny on “Sick Fat”

23 Schools Can Help with

Learn about the emerging issue of “sick fat” and how it could affect you

18 308: My Answer

to Julie’s Question

Bryan Campbell’s response to the former Biggest Loser contestant

19 Body Composition, Fat Distribution and Obesity: Impact on South Asians Learn how overweight and obesity affects others around the world

Learn about the history of weight loss medications and explore what’s new

Childhood Obesity

Discover how schools can play vital roles in helping children develop healthy lifestyles

24 Kidz Zone 26 Letters from Readers ONLINE EXCLUSIVES A Day with Julie

Read more about eating and training with Julie, this issue’s feature success story

How the Brain Controls Your Weight

Learn what role the brain plays in your appetite w w w. p o w e r o f p r e v e n t i o n . c o m

Power of

revention®

Power of THE Magazine

Prevention

Power of Prevention®, published by the American College of

®

Endocrinology (ACE), the educational and scientific arm of the American Association of Clinical Endocrinologists (AACE), is dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health. Designed as an aid to patients, Power of Prevention

Donald C. Jones Chief Executive Officer, AACE

includes current information and opinions on subjects related to endocrine health. The information in this publication does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other

AMERICAN COLLEGE OF ENDOCRINOLOGY

acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations

steven m. petak, md, jd, face, fclm President, ACE

unique to the institution or type of practice may be appropriate.

Bill Law, Jr., MD, FACP, FACE President Elect, ACE

The ideas and opinions expressed in Power of Prevention do not necessarily reflect those of the Publisher. ACE is not

donaLD A. BERGMAN, MD, FACE Chair, ACE Power of Prevention Committee

responsible for statements and opinions of authors or the claims made by advertisers in the publication. ACE will not assume responsibility for damages, loss, or claims of any kind

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arising from or related to the information contained in this

jeffrey r. garber, MD, FACP, FACE President, AACE

services mentioned herein.

Daniel Einhorn, MD, FACP, FACE President Elect, AACE

Material printed in Power of Prevention is protected by

publication, including any claims related to products, drugs, or

copyright. No part of this publication may be reproduced or transmitted in any form without prior written permission from

AACE PUBLIC & MEDIA RELATIONS Bryan Campbell Director of Public & Media Relations and CAP Representative

Power of Prevention, except under circumstances within “fair use” as defined by US copyright law. © 2008 ACE.

Power of Prevention is published by the American College of

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Endocrinology, 245 Riverside Avenue, Suite 200; Jacksonville,

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info@aace.com, Web site www.aace.com.

FL 32202 • 904-353-7878 • Fax 904-353-8185 • E-mail

AACE is a professional medical organization with more than

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6,000 members in the United States and 84 other countries.

Founded in 1991, AACE is dedicated to the optimal care of

TRAVIS CHEATHAM Director of Graphic Design

patients with endocrine problems. AACE initiatives inform the public about endocrine disorders. AACE also conducts

JEFF HOLLOWAY Graphic Designer

continuing education programs for clinical endocrinologists, physicians whose advanced, specialized training enables

AMY OGLESBY Graphic Designer

them to be experts in the care of endocrine diseases, such as diabetes, thyroid disorders, growth hormone deficiency, osteoporosis, cholesterol disorders, hypertension and obesity.

Contributing Editors Nathalie A. Turner, MS, ELS Medical Literacy Editor Obesity Issue, Power of Prevention® Magazine

ACE is a scientific and charitable medical organization dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health.

What is

OBES I T Y ?

Dear Reader, Overweight and obesity are major public health problems in this country and around the world. As most of you know, obesity raises the risk of many medical conditions. These conditions include type 2 diabetes, high blood pressure, high cholesterol, heart disease, depression, arthritis, sleep apnea, gallstones, breast cancer, uterine cancer and blood clots. Two out of three Americans are currently overweight or obese, and this proportion is even higher in minority populations.

The label “obese” is not meant to be an insult. Obesity is a disease defined by a body mass index (BMI) of 30 or more. BMI is how one’s weight relates to one’s height. It is calculated by dividing the weight in kilograms by the height in meters squared (see example).

For most of us, it is easier to use a BMI calculator on the Internet. You can find one at our Power of Prevention Web site, (http:// www.powerofprevention.com/bmi.php).

P

The BMI predicts the risk of medical problems and death. At a BMI of 25 one becomes overweight and health risks start to go up. The higher the BMI, the higher the risk. BMI has its limitations because it does not measure how much fat versus muscle your body has. BMI may overestimate health risk in people who are highly muscular. BMI may underestimate body fat in people with muscle wasting. Another easy way to estimate body fat is to measure waist circumference. Waist circumference estimates abdominal or visceral [VISS-er-uhl] fat, the worst type of body fat. A waist circumference of 35 inches in women or 40 inches in men raises the person’s health risk.

Once you have obesity, it is very difficult, but not impossible, to lose weight. The key is really to prevent obesity by restricting food intake and being physically active on a regular basis. This plan must be followed for life. Metabolism naturally slows as one gets older and it becomes harder and harder to keep off the excess pounds. We hope that education and action to prevent obesity begins in childhood and continues through adulthood.

This issue of Power of Prevention® Magazine was written by experts in endocrinology and nutrition to help our patients. The authors explain how humans regulate stored body fat. They discuss cutting-edge technology to evaluate fat mass and body composition. They discuss the health problems associated with obesity. They also talk about the medical and surgical treatment options for obesity. There are many practical tips for losing weight. The authors also discuss childhood obesity and the role of parents and schools in addressing this disease. Finally, there are stories of some people who were successful at achieving significant weight loss and how they did it.

We encourage all our readers to take action. Share the information in this issue with friends and family. Join us in our efforts to prevent and treat obesity!

Thank you, Elise Brett, MD, CNSP, FACE and J. Michael GonzÁlez-Campoy, MD, PhD, FACE Guest Editors Elise M. Brett, MD, CNSP, FACE, is a clinical endocrinologist in private practice in New York City. She is Assistant Clinical Professor at Mount Sinai School of Medicine and is a Certified Nutrition Support Physician (CNSP).

J. Michael González-Campoy, MD, PhD, FACE, is Medical Director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME). He earned his MD and PhD from Mayo Medical School and Mayo Graduate School of Medicine in 1991. He is board certified in Endocrinology, Diabetes and Metabolism. Dr. GonzálezCampoy is a recognized national expert on diabetes and obesity and a proponent of adiposopathy as a treatment target. Dr. González-Campoy is Clinical Assistant Professor of Medicine at the University of Minnesota.

E X A M P LE A person weighs 190 pounds and height is 5 foot 10 inches (70 inches)

• First convert pounds to kilograms

by dividing by 2.2.

[190 ÷ 2.2 = 86.3]

• Then convert inches to centimeters

by multiplying by 2.54.

[70 × 2.54 = 177.8 cm]

• Divide centimeters by 100

to get meters

[177.8 ÷ 100 = 1.778]

• Multiply meters by meters to get

meters squared

[1.778 × 1.778 = 3.16]

• Divide weight by meters squared

to get the BMI

[86.3 ÷ 3.16 = 27.3] = overweight

POWER OF PREVENTION • Vol. 1, Issue 3

1

JULIE HADDEN:

The Biggest Loser Contestant Weighs in on Life after the Show

By Bryan Campbell

A stay-at-home mom got the opportunity of a lifetime. But now that she has her life back, she’s struggling to maintain balance between family, fame and her new healthy lifestyle.

The Biggest Loser For Julie Hadden, going on national television and losing 97 pounds was the easy part.

Living a “normal” life, raising two kids, working as a stay-athome mom, and trying to maintain a healthy lifestyle – now, that’s hard.

Julie was a contestant on the hit NBC show The Biggest Loser.

Her motto for the season was “To finish what I started, for once.” And Julie was determined to take advantage of this once-in-a-lifetime opportunity. After she struggled to lose weight in the beginning, she used her sense of humor to deflect her frustration. But she would not give up.

Like many overweight people, Julie developed her selfdeprecating humor at a young age as a defense mechanism.

Julie was a self-described “fat girl” growing up. As she grew

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POWER OF PREVENTION • Vol. 1, Issue 3

older, she began to realize the problems with her weight went beyond name-calling on the school yard.

“You just don’t think about things like riding on a rollercoaster or an airplane,” Julie explains. “People don’t even realize that sitting in a booth at a restaurant can be terrifying. I had to wait for a table because the booth was uncomfortable. Things like that should not be a part of your thought process but they are.”

But, unfortunately, as millions of Americans know, it’s not just physical discomfort that affects overweight people. There is a mental weight to match the physical one. For Julie, she never felt comfortable in her body. She felt she was never able to enjoy certain activities with her friends, like shopping.

Julie’s husband, Mike, knows all too well how the inability to do this simple thing impacted Julie’s mental and physical condition.

“She would not only be upset about the size she had to wear, but about the way she looked in her clothes,” Mike says.

“And I’m not kidding you, it would send her into an eating binge and depression for a long time after that.”

“You know why fat women always have a lot of nice shoes,” Julie says. “It’s the only thing they can just walk into a store and buy.”

“Broccoli, I got him addicted to broccoli,” Noah exclaimed, referring to one of his close friends.

Before The Biggest Loser, Julie had tried every fad diet around with no success. Sure, she would occasionally reach her shortterm goals, but she would always bounce back and gain even more weight. Once, she lost 20 pounds just to fit into a bridesmaid’s dress at a wedding. She was so proud of starving herself for weeks, she proceeded to “eat everything in sight” at the reception.

“His friend never had broccoli,” Julie says. “And another friend never had grapes. GRAPES! I mean really—grapes!”

Julie’s physical health was at risk by the weight she was carrying. Before the show, Julie had 60% body fat, as well as two major health conditions; polycystic ovarian syndrome (PCOS) and prediabetes.

All of these reasons were what led Julie to commit to finishing what she started on The Biggest Loser. It took many weeks of careful nutrition and extreme physical activity before the weight actually started coming off. But once it did, Julie began to shed the pounds in a big way.

By the time of the show finale, Julie proudly broke through that old image of herself, and weighed in at 121 pounds.

Although she came in second place, the changes in her life are so dramatic that Julie considers herself a winner to this day.

Coming Home Working out for 6 hours a day and eating only healthy choices is easy when you are living on the set of a television show. But that’s not reality. That’s not the world that you live in and it’s not the world I live in. The odds are, you will never be cast on a television reality show to lose weight, so how can Julie’s story inspire you?

The truth is, for Julie and many of the contestants on The Biggest Loser, the hardest part about losing the weight is coming home.

When Julie returned to her Jacksonville, Florida home, she immediately realized that things were going to be different. Old lifestyle choices and familiar behaviors are easy to slip into. Julie quickly realized that she needed to bring her entire family into a new lifestyle. So she started with her son, Noah.

“He was starting to learn how to read when I came back and I didn’t want to just take everything out of the pantry and throw it away,” Julie says. “So we played a game. We went through the pantry and I made him look at every label. I made him read it and if high fructose corn syrup was in the first three ingredients, we threw it away.”

It didn’t take long for young Noah to buy into Mom’s new lifestyle. Noah is obsessed with The Biggest Loser now, and even has a life-sized picture of Julie’s trainer from the show, Jillian Michaels, on the wall of his bedroom. And the great news is, Noah is doing some influencing of his own.

Julie is proud that she can pass along what she has learned about nutrition to her sons. She tells a story of a time Noah passed all the sugary drinks at a birthday party and asked the hostess if there was any bottled water. The look of joy on Julie’s face as she tells the story demonstrates just how proud she is, and what a difference a little nutritional education has made in their lives.

Eat Less, Move More But it’s not just about eating right. In the 2 years since she has been on the show, Julie has maintained her weight loss. That is a daily struggle for her. Almost every day, someone comes up to her at the store, at church, or on the street and asks, “How did you do it? What’s the secret?”

“I have tried to find a secret. And my answer is, there is no secret,” Julie says. “It’s eating less and moving more, plain and simple. Trust me, I’ve tried every way to cheat that I could, and you just can’t.”

Moving more doesn’t just mean exercising at the gym. Yes, Julie does spend time at the gym, and takes part in a boot camp course three times a week (see online exclusive).

“It becomes a part of your life,” Julie explains. “To get that outlet and to have my alone time and to have those endorphins and that endorphin rush, it really does change your mental state.”

But now, Julie also incorporates movement into everything she does, including family time.

“What we used to do as a family was sit around and watch TV all the time,” Mike says. “We didn’t go outside. Julie has talked about how she was embarrassed to go out in public. Her whole life was spent trying to avoid people who had known her when she was thinner, so we would never have gone to the beach or gone to the pool or anything as a family. We wouldn’t have gone to the park or anything that required physical exertion, so we’d sit at home and probably eat junk food on the couch while we were watching TV.” Continued on page 6

POWER OF PREVENTION • Vol. 1, Issue 3

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State of Health Losing nearly 100 pounds and half of her body weight has drastically improved Julie’s physical and mental health. She takes fewer medications for her medical conditions, feels better than she ever has, and has more energy throughout the day. And she’s not alone. Julie can go through a list of her friends and teammates on the show; each one with a serious medical condition before losing the weight. Now, most of them have seen dramatic improvements in their health. Many no longer require medications for cholesterol, high blood pressure and diabetes. All of them feel better in their day-to-day lives.

“I have seen diet and exercise change major health problems in many people,” Julie says.

But Julie’s physical health has improved much faster than her self-image.

“I still have issues,” Julie admits. “I’m not a swimsuit model.”

While her body has changed, Julie confesses that she still struggles some with her self-image. “I’ve had these illusions of grandeur that once I was in the size I wanted that I would be hot stuff and I would never worry about issues like that again,” Julie says. “But I do. Your body image has to come from something other than a scale or a reflection in a mirror. Until it changes in your head, until you feel proud of yourself and sexy and confident, a lot of times you won’t see the result you are looking for. Because you aren’t going to be perfect, ever.”

Julie is in a rare position to empathize with people who have a long way to go to meet their goals, and people who are seemingly much closer. “[Before the show] when I saw someone who would say ‘I understand, I really need to lose 15 pounds’ I would roll my eyes and say ‘give me a break,’ but now that I have been struggling for the past 2 years to maintain this weight, I’ve realized that somebody’s 15 pounds can be just as important to them as someone’s 100 pounds.”

But according to Julie, the hardest part is truly motivating yourself to start the lifestyle change. She says that comes from being honest with yourself, and realizing what it is in your life that’s holding you back.

“For me it had a lot to do with worthiness and making myself a priority,” Julie explains. “I really like people to sit down and be honest and say, ‘Look, you’re fat. You didn’t get this way by accident. Why are you fat? It’s not just about eating; it’s not just about not exercising. There are other issues.’”

Finishing What She Started Julie laughs when you talk about her motto from the show.

“It means I will never be done,” Julie asserts. “It can’t be about a diet, it has to be about a lifestyle. You can’t live on a diet forever. I will have to continue to work out and I will have to watch what I eat for the rest of my life. But at the same time, the benefits that come from that, I get to live a healthy lifestyle and actually participate in my children’s life and not just watch them from the sidelines. I may actually get to see my children get married. I may actually get to see my grandchildren grow old… that to me is worth whatever price I have to pay!”

Spending time with Julie Hadden is an inspiration for anyone who needs to lose weight, has problems with a positive selfimage, or simply believes in the power of the human spirit.

Julie has collected her thoughts, advice, and stories into a new book called Fat Chance: Losing the Weight, Gaining my Worth. You can find the book on amazon.com, or on powerofprevention.com.

Final Thoughts As the long interview with Julie came to a close, I asked one final question. If Julie could speak to you, right here, right now, what would she say to you? Here is her complete response: “Before you ever get started, before you ever lose a pound, before anything else changes, you have to believe that you are worth the effort. You have to believe that it is possible to change and that you can definitely do it. I am living proof that you can. But until you make that change, until you believe in your mind that you are truly capable and worthy of living the life that you desire to live, nothing else will truly be right. And I think once you have that mindset, once that changes, everything else will fall into place because the truth is, The Biggest Loser diet is not the end-all be-all. There are lots of nutrition plans that will work if you do not quit. And I think until you understand that you are worth fighting for, and you deserve to be a priority in your own life, and you deserve to go the distance, then that’s the only thing that’s going to make you not quit. Because it’s not fun and it’s not easy and it’s a difficult process…but it’s so worth it in the end.”

“To finish what I started, for once.”

As I thanked Julie, Mike and Noah, and prepared to free them for their afternoon in the pool, Julie decided it was time to ask me a question.

Since she returned home, she’s taken on a new motto.

“Is there something you would like to say to the readers out there?”

“To continue what I started, forever.”

As a matter of fact, there is… (see article page 18)

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POWER OF PREVENTION • Vol. 1, Issue 3

P

DXA: A New Way

B y M a ry K . Oat e s , M D , a n d S t e v e n M . P e ta k , M D , J D , F A C E , F C LM

Mary K. Oates, MD, graduated from Ohio State University College of Medicine in 1990 and the University of California, Irvine residency program in Physical Medicine and Rehabilitation in 1994. She has been specializing in the diagnosis and treatment of Osteoporosis since 1997 and is a Certified Clinical Densitometrist. Both Dr. Mary Oates and Dr. David Oates are faculty advisors to FORE (Foundation for Osteoporosis Research and Education).

Together, they provide instruction for the limited license school for DXA technologists at their Santa Maria office.

Has your doctor ordered a DXA (dual energy x-ray absorptiometry) scan to test your bones for osteoporosis? The same machine that is used to evaluate your spine and hips for brittle bones also takes a full-body image of your fat, muscle and bone. It is called DXA Total Body Composition Analysis (DXA-TBCA). DXA-TBCA can precisely monitor how much fat you lose during weight loss or how much muscle you gain during a physical activity program. Better yet, it can show all of these changes at one time, or over the course of a weight management program.

Steven M. Petak, MD, JD, FACE, FCLM, has been an associate at the Texas Institute for Reproductive Medicine and Endocrinology since 1989 and is also the Director of the Bone Densitometry Unit and Osteoporosis Center with the Institute. Dr. Petak received his MD degree from the University of Illinois Medical School in Chicago. He completed three years of training in general internal medicine at the University of Texas Medical School in Houston where he also completed a three-year Fellowship in Endocrinology and Metabolism. Dr. Petak is the President of the American College of Endocrinology (ACE).

to Monitor Weight Loss

For this test, you simply lie fully clothed on a padded x-ray table for 5-12 minutes. The x-ray exposure is minimal – less than the amount of natural radiation you receive each day from the environment. The test reports your total body fat and the amount of muscle and bone in your body. It also gives you a dramatic, very personal, full-body x-ray picture. It can clearly show you and your doctor if you have excess fat around your waist. This type of fat is known to lead to heart disease, diabetes, high cholesterol, and high blood pressure.

There are older, less sophisticated methods to assess body composition that are still widely used today. They are readily available at gyms, offices and even at home and on the Internet.

FIGUR E 1 A PR IL 2 0 0 6 54% fat 2 31 lb s

• The digital scales that give a percentage fat reading are actually a form of Bioelectric Impedance Analysis, known as BIA. These scales give total body fat readings, but cannot show you the fat distribution in your arms, legs or waist like a DXA-TBCA scan can.

• Skinfold measurements, or the “pinch test,” measure the fat underneath the skin at various sites with calipers. These measurements do not estimate the deep fat around the waist.

• Your doctor may also use a measuring tape to measure your waist and hip circumference. The waist to hip ratio (WHR), which is the circumference of the waist divided by the circumference of the hips, has been used as a simple method for determining body fat distribution. Health risks have been shown to increase with increasing WHR, although the standards for risk vary with age and gender.

If you have been tested by any of these methods, realize that the values are not the same. DXA-TBCA gives you the most valuable information because it gives you fat, muscle and bone values.

DXA-TBCA reports provide fat mass, muscle mass, and bone mineral content for the whole body, waist and hip region, arms, legs and trunk.

Absolutely no other body composition method can provide these regional values for body fat distribution. The DXA-TBCA waist and hip region is particularly important, because we can measure abdominal fat, which

is recognized as an important predictor of the health risks of obesity. This is the analogy of the “apple and pear” body shape. People with an apple shape have more fat in the waist, and they have a higher risk for high blood pressure, type 2 diabetes, high cholesterol, heart disease and early death. People with a pear figure have more fat in the hip and thigh area, and have a lower health risk. Researchers have found that DXATBCA is able to determine cardiovascular and metabolic syndrome risks by looking at percent total body fat and regional values. Our research has shown that healthy, active men will have an average body fat of about 20% and women will average about 30%. Contrast this to some F IGUR E 2 of the contestants on the NBC reality weight DEC 2 0 0 6 1 7 .6 % fa t loss show The Biggest Loser. These contestants 1 2 5 lb s started the show with body fat in the 50% range. We used DXA-TBCA to follow their dramatic weight loss (Figs. 1, 2). On the other end of the spectrum, serious athletes, like male track and field athletes average 13% total body fat, and swimmers average 16%.

DXA-TBCA can be found today in many medical practices, especially those that help people lose weight. Endocrinologists, internists and rheumatologists that already offer DXA for osteoporosis testing also may offer DXA-TBCA. Executive wellness programs and insurance physicals sometimes bundle these procedures with nutritional consultations and physician-directed weight loss programs. You may also want to ask if they do resting metabolic rate (RMR) testing. RMR is the amount of calories your body burns in a day when it is at rest. This can be helpful to identify a daily calorie limit to induce weight loss.

DXA-TBCA scans can be a powerful motivational tool for patients in weight-loss programs. One advantage of using DXA-TBCA in monitoring weight loss is that we now can see that if you lose 20 pounds, it could be from losing 20 pounds of fat, or from losing 30 pounds of fat and gaining 10 pounds of muscle. This is especially helpful as patients reach plateaus on the scale. DXA-TBCA can show that in reality they are continuing to lose fat and adding muscle. P POWER OF PREVENTION • Vol. 1, Issue 3

5

What are the

Complications of Obesity?

By Dace L. Trence, MD, FACE

W

ho would not like to look thin?

Going to a wedding or reunion? Want to get into those jeans that fit so well just a few years ago? We cannot escape the changes that happen to our body over the years. But being overweight has consequences beyond how we look or how we might not fit into old clothes.

Obesity is a disease because it can shorten your life and because it causes complications. Obesity causes problems with your body, your metabolism, and your mental health.

Let’s discuss some of the problems caused by obesity.

People with higher weights have shorter lifespans. If a person is obese at the age of 40, life will be shortened by 7 years. This shorter life expectancy is from weightassociated effects alone. Obesity also causes many lifeshortening conditions: • Ninety percent of people who develop type 2 diabetes will have a body mass index (BMI) greater than 23.

• The risk of getting type 2 diabetes is highest if the weight is gained during childhood and there is a family history of diabetes, abdominal obesity, or mother having had gestational diabetes.

6

High cholesterol, elevated blood pressure and the presence of diabetes in turn lead to increased heart disease.

• In a study with over 300,000 people followed-up over 7 years, every unit increase in BMI led to a 9% increased risk for heart attack.

• In the same study there was an 8% increased risk of stroke.

• In women with obesity plus high blood pressure, 70% will develop an enlarged heart and 14% will get heart failure.

Breathing capacity can be affected by having obesity.

• Sleep apnea (halted breathing during sleep) is much more common in those who have obesity.

• Asthma is more common as BMI goes up.

• Collapse of lung tissues and more lung infections are more common after anesthesia for surgery in patients with obesity.

• If you have obesity, the chance of developing high blood pressure is up to five times greater compared to someone with a normal weight.

In joints that carry excessive weight, such as the hips and knees, arthritis tends to be a problem. There is also evidence that other joints, like the ones in the hands, might also be more involved. And gout is also more common.

• Eighty-five percent of those diagnosed with high blood pressure have a BMI above 25.

Not as well known is that many cancers are more common in patients with obesity.

• Increasing cholesterol levels are associated with weight increases above a BMI of as little as 21.

• The World Health Organization International Agency for Research into Cancer has estimated

POWER OF PREVENTION • Vol. 1, Issue 3

that being overweight (and also sedentary) might account for up to 25-30% of cancers of the breast, colon, uterus, kidney and esophagus.

• About 10% of all cancer deaths that are not from smoking are related to obesity.

• In women who have obesity there are more thyroid cancers, leukemias, multiple myeloma, and pancreatic cancers.

• In men who have obesity there are more thyroid cancers, malignant melanomas, multiple myelomas, gallbladder cancers, and leukemias.

Even fertility is decreased by obesity.

• In women, 6% of those who are obese have trouble conceiving.

• When a pregnancy occurs, the chance of a serious event requiring hospitalization is 4-7 times greater for a woman with obesity compared to a woman who is lean.

• Gestational diabetes, difficulty with blood pressure control (pre-eclampsia), difficulties while in labor and delivery, higher c-section rates, and more deaths of the mother and/or fetus, are all associated with obesity.

• Children born to mothers who have obesity are more likely to be large. Large birth weight increases the risk of infants developing diabetes in later life.

• Men are also affected by obesity. Obesity causes erectile dysfunction (impotence) and lower fertility.

Many men have low testosterone (male hormone) because they have excess abdominal fat.

Gallbladder disease is more likely in obesity.

• Compared with women who are lean, women with a BMI of over 32 have three times the risk of gallstones.

• In women with a BMI over 45, this risk is seven times higher.

• Changes in the liver that resemble alcoholic liver disease (known as fatty liver) can be seen with obesity. In 50% of patients, these changes will lead to fibrosis of the liver. In 30% cirrhosis will develop, and 3% will go on to develop liver failure.

Being obese also can affect kidney function. The kidney cannot filter well in people with chronic obesity. So kidney function is decreased by having excess weight alone.

Finally, the effect of obesity on emotional well-being is important to understand. In most societies, people with obesity are viewed as less desirable marriage partners, less likely to be promoted in their jobs, and tend to earn less than their more ideal-weight peers. Obesity can cost more, for example, many airlines now charge for two seats for a person with obesity. It is not surprising that obesity increases the risk of major depression. In turn, depression can lead to binge eating disorder and night eating disorder. Depression causes a vicious cycle leading to more weight gain.

Putting it all together Obesity is a disease because it causes problems with your physical, mental and metabolic health. We have discussed examples of the complications of obesity. If you are unable to lose weight on your own, get help from your doctor.

Chances are that it is not just the weight. Chances are you do have complications of obesity. Everyone who has obesity deserves a thorough medical exam at least yearly.

Clearly, the risk for many medical complications is increased with obesity. Even Hippocrates wrote so many years ago: Corpulence is not only a disease itself, but the harbinger of others. P Dace L. Trence, MD, FACE, completed undergraduate degrees in Biochemistry and Microbiology through the College of Biological Sciences at the University of Minnesota and her MD degree from the University of Minnesota Medical School. She completed an internal medicine residency through Northwestern Hospital in Minneapolis and, subsequently, returned to the University of Minnesota for Endocrine Fellowship. Dr. Trence started practice with Group Health, Inc, in Minnesota, becoming Chief of Endocrinology, initiating several programs, including a Lipids Clinic, Diabetes Foot Care Clinic, and a Diabetes and Pregnancy Clinic.

After moving to Seattle to practice at Group Health of Puget Sound, becoming Chief of Endocrinology, then Chief of Medical Subspecialties, she then joined the faculty at the University of Washington.

Currently she is an Associate Professor in the Department of Medicine, Director of the Diabetes Care Center and Director of the Endocrine Fellowship Program at the University of Washington.

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Medical Nutrition Therapy B y E l y s e So s i n , R D

“L

ose Weight.” “Eat Less.” “Exercise More.” “Get Motivated.” You hear it from your doctor, people on television, and even government spokespeople, and you read it in magazines. There are endless so-called solutions to the issue of excess weight, but almost all are short-lived.

Regardless of the push to lose weight, the percentage of overweight and obese people continues to climb in the United States. There are those who still look for the magic bullet. There are also those who are willing to work hard to lose weight but do not know what to do or whom to believe.

It can all seem so overwhelming.

Even people who know how to eat with good health in mind may have trouble losing weight. There are many reasons for weight gain: genetics, environment, socioeconomic level, career obligations, peer pressure, social obligations, certain medications, and habits developed over a long period. Some approaches to weight loss seem obvious and practical but in fact are often overlooked or not attempted. So, rule number 1 is to start with a single change and then add to it. Let’s consider some possible changes.

Portions From muffins, steak, hamburgers, pizza, pasta, bagels, and even fruit, the size of food portions has increased over the years. And our eyes are now accustomed to big, bigger, and biggest, and that is what we eat. What can you do?

• Check out www.mypyramid.gov to determine whether you have been underestimating your food portions.

•

Don’t forget the condiments – mayonnaise, butter, oil, salad dressing, pesto, and ketchup. The condiments that are added to food to enhance taste count too, and sometimes contain more fat, calories, and sodium than the food to which these are added.

• Don’t assume that a drinking glass contains 4 or 8 ounces. You may be surprised to find that your glass holds 12 or 16 ounces.

• Most people have no idea how much rice, pasta, or dry cereal they consume. Measure these foods once, and you may be surprised at the amount you eat.

• Check out the size of a steak or chicken or even fish. Many people tend to consume two or even three times the amount of protein they really need, especially at the dinner meal.

Restaurants Dining out is a way to socialize, conduct business, or simply eat a meal. Most people eat more food at restaurants compared with home-cooked meals. What can you do?

• Choose a restaurant with reasonable choices and moderate portions.

• Try to order first; that way you won’t change your food selection if you see or hear someone order another option that is less healthy.

• As annoying as it may be, when you order a salad, insist on having the dressing on the side. And you can save hundreds of calories by adding less dressing yourself.

• Entrees are often the equivalent of two portions (see above). Order two appetizers instead. Share an entrée or

order the entrée you want and before it is brought to the table request that ½ is placed in a “doggy bag.”

• Some restaurants have menus with calorie counts. Take a look at the counts and consider the amount of calories you will be consuming.

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• Ask the server how the food is prepared so that you can make the best decision. “Fried,” “scalloped,” or “crispy” should be a red flag that means more calories and fat.

•

Ask the server not to bring bread, or take the amount you want to eat and then ask to have the basket removed. If this is not possible, at least move the basket away from you. If extra food is within reach, chances are you will eat more than you need to.

•

People spend a much longer time dining at a restaurant than at home, and will eat more food over time. When you are finished with your meal, ask the server to remove your plate. That way you will avoid eating more while waiting for others to finish.

• Free food? Whether someone else is picking up the bill or you know the owner of the restaurant, the calories still count!

• Drinks? If you need a drink, stick with one, or a wine spritzer, or club soda.

Fluids Alcohol, Vitamin Water, Gatorade, juice, smoothies, Starbucks coffee drinks with milk and sweeteners, and Jamba Juice may contain a lot of calories. What can you do?

• Check the portion size of these fluids because they can range from 8 to 32 ounces, adding hundreds of calories.

Triggers

A person, place, or thing may encourage people to eat more than they want or need. Some people encourage you to eat a lot, order dessert, or have drinks (alcohol). Popcorn and a soda are almost a must in a movie theater. What can you do?

• Recognize your own triggers and have a strategy.

Stress and the damage it causes are facts of life and contribute to overeating. What can you do?

• If someone at your table wants to order dessert, remember that you do not have to have dessert too.

• Decide that you will have a dessert on occasion, but not every day.

Physical Activity Everyone should have physical activity every day, regardless of his or her weight. The many benefits of daily physical activity include physical and emotional changes that improve your health and lifestyle. What can you do?

• If you have been sedentary, start slowly with any physical activity routine (check with your physician to make sure that you are ready to start a program or routine).

• Do not choose something you dislike, as you will not stay with it very long.

• Try to eventually have a few different types of physical activity you can perform. You will reduce the boredom factor and have a more versatile physical activity program.

• Find a friend or relative to be physically active with you.

Even your dog can be your physical activity buddy.

• “Natural,” “pure,” and “organic” juices or drinks still contain a lot of sugar and calories.

Stress

• Get a support system in place and use it as you go through the weight loss process. It can include your doctor, nutritionist, trainer, sister, or friend.

Weigh-ins Measuring success can be very tricky. Some people weigh themselves daily but some people do better with weekly weigh-ins. Success is not just the number on the scale but also the new habits that are created along the way. And remember that fluid retention can contribute to the weight seen on the scale. What can you do?

• Decide where you are going to weigh yourself. If you think a scale at home will be difficult in that you weigh yourself too much, try the scale at the gym, doctor’s office, or best friend’s or relative’s house.

• Decide how often you will weigh yourself and stick with it.

Realistic food plan It took a while to gain the weight and it will take a while to lose it. Some food plans are too strict or restrictive and can set you up to fail because you get too hungry and the lack of calories is too drastic. What can you do?

Continued on page 10 POWER OF PREVENTION • Vol. 1, Issue 3

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Medical Nutrition Therapy conti nued

• Subtracting 500 calories from your daily intake (from less food or from less food plus physical activity) will result in a 1-pound weight loss in 1 week (3500 calories = 1 pound). One pound per week is a reasonable rate of weight loss for most people.

• Eating three meals daily tends to curb overeating.

• Include foods you enjoy. If you eliminate all the foods you love you will become bored and eventually you won’t follow your food plan.

• Low-fat food is helpful for some people, but for others it isn’t satisfying and hunger returns too quickly. And for some, such food is a green light to eat large quantities.

Grazing / eating off other peoples’ plates / clearing plates / cooking This may sound funny, but hundreds of calories are consumed this way, and often the person is not even aware that he or she is eating. What can you do?

• Eat only when sitting at a table.

• Do not eat while you are on the phone, reading, on the computer, or watching television.

• Eat only from your own plate.

Food logs This is a key to weight loss. What can you do?

• Recognize your eating patterns. For example, how does the food intake change on the weekend compared to during the week? How much food do you eat when you are not really hungry? These pieces of information are keys to changing behavior. Accountability works!

• Purchase a notebook and record the time of eating, food, and approximate portion size. Other categories may include mood, hunger level, physical activity, location where the food was eaten (home, office, restaurant).

• Recording the food log can be done as the day goes on or, if time does not allow you to do it throughout the day make sure you write in the log at the end of the day. Try not to wait until the next morning. You will probably forget some of the food.

• Using the log to tally up daily calorie intake can also be helpful for some people to manage their food intake or to explain why someone may not be losing weight.

Short- and long-term goals Both are important. You must be able to achieve a shortterm goal and continue to the next short-term goal and feel a sense of accomplishment along the way to the longterm goal. What can you do?

• Goals must be realistic and allow for plateaus and sometimes even setbacks.

• Realize that success in losing weight is about lifestyle changes over time. Your food intake and physical activity level will not always be what you planned, so strive for improvement.

During her twenty-year career as a nutritionist in private practice, Elyse Sosin, RD, has counseled children, adolescents, and adults on weight management, wellness, eating issues, pregnancy, gestational diabetes, and hyperlipidemia. Previously, Ms. Sosin was on the staff of Mount Sinai Medical Center as a Nutritionist at the Medical Center as well as the Adolescent Health Center and the Women’s Center. Ms. Sosin has lectured at public and private schools, colleges, organizations and medical facilities and has been a consultant to several food and publishing companies. She has appeared on television, and has been quoted in The Daily News, The New York Times, The Post, and other publications.

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• Losing weight takes time and effort. But there is nothing better than feeling good and improving your health.

• Write down everything you eat and the quantity so you can identify the relationship of your eating history with your short-term weight change.

To conclude, losing weight is complex. You have developed certain habits over the years and are now trying to change them. Just starting the process should allow you to feel better and eventually will enhance your health. Make time for yourself, because no one can lose weight for you. P

Newfound Simplicity

NOW

By Sarah Senn

A self-proclaimed “all-or-nothing dieter,” Kathy Gallagher has struggled with her weight from an early age. Home-cooked, family-style meals did not afford her any breaks as a child. Kathy continued to struggle with her weight through high school and up until she got married. At her peak, Kathy weighed 290 lbs.

Kathy, who has worked for the City of St. Paul, Minnesota, for over 30 years, has tried every diet in the book, including one that restricts you to one hamburger and one candy bar a day. The success of those diets was short-lived and the results never lasted longer than a few months.

“I told myself, ‘If I keep doing what I’m doing, it’s never going to change,’” she remembers.

After reading countless articles about the serious complications of obesity, Kathy became even more motivated to lose weight when one of her friends had gastric bypass surgery. Determined not to be left behind, she started with baby steps by eating less and moving more.

In just a few weeks, Kathy began to shed the pounds.

I told myself, “If I keep doing what I’m doing, it’s never going to change.”

Realizing the difficulty of losing weight by herself, Kathy formed a support group with a couple of her friends where they could meet weekly to share the burden and encourage each other. Together, the group confronted the challenges of losing and maintaining weight and proved the value of strength in numbers. Kathy acknowledges that while her friends were essential to her success, she could not have accomplished her goals without the support of her husband and family as well.

THEN

Now at age 53, Kathy weighs 165 lbs and is healthier than she’s ever been. She maintains her weight by eating well-balanced meals and staying active. Kathy’s recent weight loss has inspired other members of her family to do the same. Her two brothers, sister-in-law and niece have lost more than 300 lbs combined.

While she admits that she still wrestles with food choices and daily workouts, Kathy has a positive outlook on life.

Her self-esteem is higher and she doesn’t worry as much about weight-related health complications.

For Kathy, the simple changes have been just as rewarding – things such as finding clothes that fit great – no more plus sizes! – and fitting into an airplane seat with room to spare have made life more enjoyable. “I marvel at the little things,” she reflects. Looking back on how far she has come in just a couple of years, Kathy can’t help but be amazed at the difference the weight loss has made in all aspects of her life.

“It is so worth it. It’s difficult, but the rewards are astronomical,” Kathy says. “It can be done,” she continues.

“You just have to believe in yourself and never let the little missteps along the way derail you.” And on those days when she most struggles, Kathy reminds herself: “It’s hard to follow a meal plan, and it’s hard to maintain your weight. But living is harder when you’re obese.” P

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Weight Loss Medications B y D av i d A . W e s t b rock , M D , FA C P, FA C E

IF AT FIRST YOU DON’T SUCCEED… Obesity is a biological and treatable disease. The question everyone should ask is “what is the risk to my health from not treating obesity?” And then one should ask, “what is the benefit and risk of using medications to treat obesity?”

To understand the use of medications to treat obesity, let’s review their history.

The use of drugs for weight loss is as old as medical practice. From as long ago as 2000 BC, Indian remedies known as ayurvedic [eye-yer-VAY-dik] herbs were used for weight loss. These herbs included cayenne pepper, licorice root and cinnamon.

In the US, medications have been used to help people lose weight. Unfortunately, several obstacles have confronted those who used these drugs in the past. Thyroid extract was introduced in the late 1800s. To achieve effective weight loss it had to cause hyperthyroidism. In the 1930s, dinitrophenol [die-nigh-troh-FEE-null], a then popular drug, was one of the first drugs that carried FDA warnings and became restricted. Dinitrophenol use was associated with cataracts, blood disorders and death. Later, rainbow pills, a mixture of many unrelated drugs, such as digitalis, thyroid, and diuretics were found to cause multiple deaths. Then amphetamines [am-FET-ah-meens] were widely available until the late 1970s. Amphetamines are now restricted because they are addicting and may cause side effects on the heart and nervous system.

In the 1990s the drugs fenfluramine [fen-FLOO-ra-meen] (previously marketed as Pondimin) and dexfenfluramine [dex-fen-FLOO-ra-meen] (Redux) were used to treat

David A. Westbrock, MD, FACP, FACE, has been in private practice for nearly 30 years in Dayton, Ohio. He is certified by the American Board of Internal Medicine in Internal Medicine and Endocrinology/Metabolism. He received his undergraduate degree from the University of Dayton and his medical degree from the Ohio State University. Dr. Westbrock is an associate clinical professor of medicine at Wright State University. Dr. Westbrock is one of the Dayton area’s premier obesity experts. He created New Profile Weight Management Center in 1998. In it, he aims to create a permanent solution for patients’ health as it relates to weight management as well as a model for preventative health care in other chronic disease states. A Dayton area resident for the vast majority of his life, Dr. Westbrock has been married for 35 years and has three children.

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obesity. Fenfluramine was used in combination with phentermine [fen-ter-meen] (Fen-Phen). Fenfluramine and dexfenfluramine were taken off the market after reports of heart valve problems in association with their use.

A popular decongestant medication used for appetite suppression, Dexatrim, was also withdrawn by the FDA. Dexatrim was associated with an increased risk of stroke in 1 in 100,000 women who took the drug for the first time.

With this history, it is not surprising that many doctors shy away from using any obesity medications.

WHERE ARE WE NOW? In the 1960s and 1970s benzphetamine [benz-FEHTah-meen], phendimetrazine [fen-dih-MET-rah-zeen], diethylpropion [die-ethyl-PRO-pree-on] and phentermine (marketed as Tenuate and Adipex) were introduced into the market. For all of these medications, weight loss is approximately 2-3 times as much as weight loss with a placebo drug (sugar pill). These medications are still available today. At the time of their approval, the recent experience with amphetamines led the Food and Drug Administration (FDA) to limit these medications for short-term use (up to 12 weeks). The concern at the time was that these medications could be addictive, like the amphetamines. This was an understandable concern at the time. Additionally, obesity was not considered a disease back then, like it is now.

We now understand that treating obesity and overweight require a long-term commitment. For this reason, intermittent use of these medications may be considered.

Intermittent use has been shown to give similar results to continuous use for phentermine. In my experience, weight regain is common after stopping the medications if the patient is not closely supervised.

There are only two FDA-approved obesity drugs for extended use.

Orlistat is available over the counter as Alli, or by prescription as Xenical [ZEN-ih-kal]. It works by blocking the absorption of dietary fat. It is less effective in people who eat a low-fat diet. When fat is not absorbed by the gut it will go right through. Possible side effects of orlistat include

oily stools, loose stools, frequent stools, and stool accidents.

These side effects are easily avoidable by eating less fat and using soluble [SAHL-you-bull] fiber. Soluble fiber holds the oily residue in the gut making it less irritating. To prevent fat-soluble vitamin malabsorption, a multivitamin should be taken every night, away from meals.

(although it is being researched) to support claims that commercially available products of hoodia are either safe or effective. As health care consumers resort to natural products from health food stores and Internet outlets, it is very important that the use of any of these products be considered only after consulting a doctor.

Sibutramine [sigh-BYOO-trah-meen], available as Meridia, works on the brain to cause early fullness.

Sibutramine may raise metabolism. It is not habit forming. Sibutramine increases serotonin [seh-rohTONE-in] levels in the brain and needs to be used with caution in patients also using antidepressants known as SSRIs (selective serotonin reuptake inhibitors). These include, for example, Prozac, Zoloft, Celexa and others.

Using sibutramine and these antidepressants together may overstimulate the central nervous system.

Metformin is now the most commonly prescribed drug as initial therapy for type 2 diabetes. It had been, until recently, the only drug for diabetes that has aided in weight loss. Exenatide and pramlintide are injectable medications recently approved for the treatment of diabetes. Both have been shown to improve blood sugars after meals as well as fasting. Both drugs slow stomach emptying, and though nausea is the most common side effect, the drugs have been shown to cause weight loss. Although these anti-diabetic medications are not FDA approved for weight loss, they have this added benefit. In addition, metformin has been shown to prevent diabetes.

In November 2009, the FDA issued a warning about sibutramine. Preliminary data from the SCOUT trial suggests that patients using sibutramine have a higher number of cardiovascular events (heart attack, stroke, resuscitated cardiac arrest, or death) than patients using a placebo (sugar pill). Although this is a preliminary review of the data, sibutramine and other medications that act on the brain have to be used with caution. Talk to your doctor about the benefit and risk of these medications.

Clearly, the blood pressure and cholesterol have to be treated independently of the weight.

Orlistat and sibutramine cause a loss of 5-10% of body weight. Most weight is lost within the first 6 months.

When continued beyond the initial weight-loss phase, orlistat and sibutramine help prevent weight regain.

There are, of course, many products touted as natural remedies for weight reduction. Two are recently the most popular, and they include acai, a fruit of Brazilian origin and hoodia, a product of the Kalahari Desert in Africa.

Acai has anti-oxidant properties and is being studied for preventing hardening of the arteries and as an anti-cancer agent, but it has no proven benefit as a weight loss drug.

Hoodia is touted in advertisements as a natural product that, as used by African bushmen, can suppress appetite.

While this claim is true, no evidence is yet available

Topiramate, zoniamide and lamotrigene are anti-seizure drugs that generally result in weight reduction. They are used “offlabel” to help with weight management, because they are not currently approved by the FDA for weight loss.

Several medications may result in weight gain. These include many of the most widely used medications to improve mental health. Ask your doctor about the weight effects of medications that you are being prescribed.

THE FUTURE – THEN TRY, TRY AGAIN… The future of obesity medications is very positive. It is recognized that obesity is not only a serious health problem for the individual patient, and new drugs to help are constantly being studied. This includes several other medications that track the chemical messages between fat cells, the stomach and intestines, and the brain.

Obesity medications should always be used in addition to ongoing lifestyle changes, with improved nutrition and increased physical activity. And remember that cardiovascular risk factors such as high blood pressure and high cholesterol have to be aggressively treated independent of the weight. P

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Is Bariatric or Metabolic Surgery Right for Me? In the ever-frustrating “Battle of the Bulge,” it is best to PREVENT weight gain. Prevention takes the form of healthy eating and physical activity. Unfortunately, many of us fall behind the curve, and over time the pounds pile on.

Based on our own personal lifestyle, genetics and medical care, we become “overweight,” or even “obese” (see http:// www.powerofprevention.com/obesity.php for more information).

If we do become obese, what are the proven treatments that our doctors can recommend? First and foremost is still a change in lifestyle. All of us can become more physically active. And all of us can control our food portions. If that doesn’t work, then there are certain medicines that help with weight loss. Medications and lifestyle changes are discussed by other authors in this issue. But sometimes lifestyle changes and medications together don’t help you lose weight. If the obesity is severe enough, then there may be a role for surgery of the digestive tract to help with weight loss.

The term “bariatric” [bah-ree-AH-trick] refers to the field of medicine concerned with weight loss. “Bariatric surgery” refers to surgery for weight loss in a person who is obese. Many of us know about complications from bariatric surgery. These complications were mostly from surgeries done in the 1950s through 1970s. During that time, many patients had life-threatening nutritional deficiencies. Fortunately, the currently approved bariatric procedures are considered to be safe and effective.

Deciding to have one of these procedures requires help from an expert. This is because each bariatric surgery has its own risks and benefits. Each decision to have bariatric surgery needs to be an individual decision.

Band Procedure

14

Bariatric procedures are right for persons with a body mass index (BMI) of >40 (extreme obesity) or a BMI >35 if there are obesity-related complications such as diabetes, hypertension, high cholesterol, or sleep apnea (halted

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breathing while you sleep). To calculate your BMI, visit www.powerofprevention.com/bmi/php.

A complete medical evaluation, including a nutritional evaluation, is needed before the surgery. Depending on one’s particular insurance policy, candidates may need to fulfill certain requirements before having surgery.

These requirements should be explained by the bariatric surgeon at the time of the initial appointment. The two most common procedures are the laparoscopic [lah-parow-SKAH-pic] adjustable gastric band (or “band”) and the Roux [roo]-en-Y gastric bypass (or “bypass”).

BAND PROCEDURE In the band procedure a plastic ring-like device is placed around the top part of the stomach near the entry of the food-pipe (esophagus). It is done with laparoscopy [lahpa-RAH-skah-pee], using instruments inserted through several small incisions in the belly. Scarring is minimal.

The effect of this procedure is to limit the amount of food entering the stomach. People who have this procedure can’t overeat, so they lose weight. The band can be tightened or loosened at any time after the surgery. This way, weight loss can be controlled: not too slow, not too fast. This procedure is associated with acceptable amounts of weight loss (14 – 60% excess weight loss after 7 – 10 years from surgery). There is very little risk for nutritional deficiencies or surgical complications. Nevertheless, one in every three people who had the band procedure develops iron deficiency and need to take iron supplements. The band procedure is gaining popularity around the world.

ROUX-EN-Y BYPASS PROCEDURE The bypass procedure is a more involved surgery. It is usually done by laparoscopy. In this procedure, food enters a smaller stomach that is created surgically. This limits food intake, like the banding procedure. The first half of the small intestine is also bypassed. This is how the Roux-en-Y procedure also gets the name “bypass.”

Digestion normally occurs in the first part of the small intestine. In the bypass, the exit to the stomach is cut and reattached to a more distant part of the small intestine. Full digestion doesn’t occur. This means there

B Y J e ff r e y I . M e c h a n i ck , M D , F A C P, F A C E , F A C N

is less absorption of food, or “malabsorption.” Since this is a more involved surgery which causes malabsorption, the risks are higher. However, the malabsorption part causes more excess weight loss by 7 – 10 years (up to 70%). People who have the bypass procedure need to be monitored regularly for vitamin and mineral deficiencies and take dietary supplements as directed by their doctor.

vitamin and mineral supplementation. A team approach to obesity, including dieticians and counselors, is required before and after bariatric surgery. P

OTHER BARIATRIC SURGERIES There are other bariatric surgeries that deserve mention: • The sleeve gastrectomy (or “sleeve”) is a relatively new procedure, not generally paid for by medical insurance.

The sleeve procedure involves the creation of a smaller stomach but without causing malabsorption.

•

The biliopancreatic [bill-ee-oh-pan-kree-AT-ic] diversion with duodenal [dew-oh-DEE-null] switch (or “switch”) is a procedure that is associated with greater amounts of weight loss. This weight loss comes with a price: more nutritional deficiencies. Sometimes “the switch” needs to be reversed because the patient loses too much protein.

This procedure is much less common.

PUTTING IT ALL TOGETHER Overall, bariatric surgery is an appropriate treatment for severe obesity in patients who are at high risk for obesityrelated complications, such as heart attacks and strokes.

Bariatric surgery should only be considered in patients who did not have success with lifestyle changes, medical nutrition therapy, and treatment with medications.

The band and bypass procedures are safe and effective. These two procedures prolong life when performed in appropriate candidates. The weight loss that comes from bariatric surgery reverses many of the complications of obesity. Type 2 diabetes typically gets much better or even disappears after the surgery.

Bariatric surgery requires a personal commitment to a lifetime of healthy eating and physical activity. Bariatric surgery also requires long-term medical follow-up to monitor for complications. And for people who have malabsorptive procedures, there is a need for lifelong

Jeffrey I. Mechanick, MD, FACP, FACE, FACN, received his M.D. degree from Mount Sinai School of Medicine in 1985.

He then completed his residency in Internal Medicine at the Baylor College of Medicine in 1988. After returning to Mount Sinai to complete his fellowship training in Endocrinology, Metabolism and Nutrition in 1990, Dr. Mechanick started his private practice in Manhattan in Endocrinology, Diabetes and Metabolic Support. Since then, he has become the Director of Metabolic Support and Clinical Professor of Medicine in the Division of Endocrinology, Diabetes and Bone Disease at the Mount Sinai Hospital. He continues to care for many patients with endocrine, diabetes and nutritional disorders, as well as train physicians in endocrinology and nutrition.

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LEARNING

TO LIVE B y SARAH SENN

Everyone needs to eat to live, but what happens when you live to eat? Yehuda Greenwald, a husband, father of four and industrial equipment salesman from New York, struggled with this question all of his life.

After years of dieting and countless hours spent working out, Yehuda continued to experience the literal ups and downs of weight loss. Despite his efforts, he kept gaining weight and his medical complications worsened. After exhausting all other treatment options, Yehuda’s endocrinologist decided that it was in his best interest to pursue a more drastic measure – bariatric surgery.

Before his surgery, Yehuda actively worked with his endocrinologist and a nutritionist to manage his condition through balanced nutrition and physical activity. For nearly 5 years, Yehuda took medication to help suppress his appetite. While he was able to lose more than 35 lbs with this treatment, after he stopped taking the medication, his weight started to rise again. Even after restricting his calorie intake and exercising at least three to four times per week, Yehuda still gained at least 2 lbs per month.

It’s okay to walk away with food on the plate.

“Everyday I would come home from work, and have to lie down immediately because of pure exhaustion,” he remembers. “I felt so drained.”

Yehuda visited his endocrinologist for a routine check-up and blood tests. Those tests revealed that he had type 2 diabetes.

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In just months, Yehuda had gained 30 lbs and was taking high doses of insulin along with 14 other daily medications.

Unfortunately, his diabetes was spiraling out of control.

It was at this point that Yehuda realized how much his quality of life was diminishing because of his weight.

“As I was getting older, given the way things were going, it was only a matter of time before I had other complications,” he says.

On January 6, 2009, Yehuda underwent surgery to put in a LAP-BAND®, which limits the amount of food that can enter the stomach. As with most bariatric surgery patients, Yehuda spent many hours in counseling with a dietitian learning to understand the physical effects of the surgery on his body. He had to adopt new eating habits and learn when he was full. In just a few short weeks, Yehuda began to see the results of the surgery and his health improved.

Before the surgery, Yehuda weighed 287 lbs. As of November 2009, he had lost 78 lbs. Now at 209 lbs., Yehuda is not only looking different, but he feels different too. As Yehuda continues to lose weight, he recognizes it’s still a work in progress. Yehuda recently went to a buffet and loaded his plate full of food out of habit only to realize that he wouldn’t be able to eat it all.

“It’s okay to walk away with food on the plate,” he admits.

Since the surgery, Yehuda has more energy and enjoys spending time with his family. He no longer snores and is able to be more active with his children. However, the most profound change that Yehuda has experienced apart from the physical weight loss is that his diabetes is under control and he only takes a few medications each day.

“I’m a regular person again,” Yehuda boasts. “The way I look at food now is that I eat food to live instead of living to eat food.” P

The Skinny on “Sick Fat” B y H a r o l d B a y s , M D , F A C P, F A C E

If you are like many people, your doctor is always telling you to lose weight. Have you ever wondered why? What’s wrong with gaining weight?

Given the number of lives affected, obesity is the greatest epidemic of all time. In many patients, obesity causes type 2 diabetes mellitus, high blood pressure, and abnormal fats in the blood (such as high triglycerides and low HDL cholesterol).

These metabolic diseases are also epidemics, and the most common diseases treated by doctors. So, here’s a challenge. The next time your clinician tells you to lose weight, ask: Why does gaining body fat cause metabolic disease, and why does losing body fat make it better? Medical science is learning how gaining body weight is unhealthy.

If you gain body fat, then your blood sugar goes higher, your blood pressure rises, and your blood fats get worse. If you lose body fat, then in most cases your blood sugar, blood pressure, and blood fats all get better. This is because fat cells and fat tissue have effects on hormones and inflammatory processes.

Body fat is a highly active organ. As we learn what fat really does, we can also understand how it can become “sick fat.”

There are two hormones made by fat cells that illustrate how fat is metabolically active. The hormone leptin allows fat tissue to communicate with the brain. The more fat tissue there is, the more leptin is made. On the other hand, if you lose fat weight, your leptin levels go down. This way, the brain is able to keep track of how much energy the body has in storage. Leptin illustrates how fat tissue communicates with other organs in the body.

The hormone adiponectin determines if fat is healthy or sick.

Adiponectin levels protect you from diabetes, bad cholesterol and hypertension. “Sick fat” cannot maintain adiponectin secretion. Thus, when adiponectin levels are low, metabolic diseases develop. For this reason adiponectin treatment is an area of significant interest. Adiponectin illustrates how fat tissue regulates your metabolism.

Leptin and adiponectin are examples of rapidly emerging science, and the concept of “sick fat”.

How does this emerging science affect you? If you eat more calories than you burn off, you may gain functional fat cells (or “good” fat cells). Most “good” fat cells exist in areas other than the belly. Adding “healthy” fat may “protect” you from getting metabolic diseases.

On the other hand, if you cannot create new functional fat cells, then your existing fat cells become bigger, bloated, and “sick.” The worst area for “sick fat” is in the belly, also known as intra-abdominal or visceral fat. “Sick fat” greatly increases your risk of getting metabolic disease. So, it is not the fact that you gain fat that causes metabolic

Harold Bays, MD, FACP, FACE, is Medical Director and President of Louisville Metabolic and Atherosclerosis Research Center (www.lmarc.com). He is board certified in both internal medicine and endocrinology and metabolism, and has served as a principal investigator for over 400 clinical trials for investigational drugs for obesity, diabetes mellitus, hypertension, osteoporosis, osteoarthritis, and other metabolic disorders. Dr. Bays has written, or has been a contributing author to over 100 scientific manuscripts and over 100 scientific abstracts. Dr. Bays also serves as an international advisor and consultant to pharmaceutical companies regarding drug development.

One focus of his research is the relationship of fat (adipose) tissue with metabolic disease.

disease. Rather, it is gaining “sick fat” that most often causes high blood sugar, high blood pressure, and abnormal fats in the blood.

When you think of body fat this way, it explains why many people who are a little overweight may live longer, and may actually do better after a heart attack. They have adequate functional fat. “Sick fat” helps explain why not all people who are overweight have metabolic disease. And it also explains why some people with metabolic disease are not overweight.

But before you think that being overweight is possibly a good thing, you should understand that too much body fat can cause all sorts of non-metabolic medical problems. Having higher levels of fat, no matter what its function, can cause breathing problems (sleep apnea), bone and joint problems (knee and hip damage, back pain, etc.), and a number of other serious health problems related to too much fat. So, what’s the message?

The bottom line is this: the best way to ensure “healthy fat” is to have a healthy meal plan, and to have physical activity regularly. The best way to make “sick fat” healthy is to shrink those bloated fat cells and get rid of that belly fat. When you lose the belly fat, you improve your fat health, which leads to better metabolic health.

Too many times we see patients who say: “If I could just get the weight off, then I know I could keep it off.” Don’t fall into this trap. Start today with the type of nutrition and physical activity necessary to keep weight off. Within months you will be at a healthier weight. Don’t make it a choice – do it now and keep it up!

Several new weight loss drugs may soon be approved to treat obesity and “sick fat.” Also, weight loss surgery (bariatric surgery) may be one of the most effective ways of treating “sick fat,” and its associated metabolic diseases. Medications and surgery are discussed elsewhere in this issue.

More good news: The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) are leading the way in exploring and better understanding the relationship between an increase in body fat and metabolic disease. You can see examples of their efforts by visiting the “Adipose Tissue Pathophysiology” Web site at http://atp.aace.com. But remember, this is emerging science. So if you find you don’t understand some of what you see on this website, that’s OK. As hormone doctors, we are still trying to sort it all out ourselves!

P

Commentary: The concept of sick fat is evolving. The use of the term “sick fat” will be addressed at a future AACE conference.

17 POWER OF PREVENTION • Vol. 1, Issue 3 - Donald A. Bergman, MD, FACE, Chair of ACE Power of Prevention Committee

[308] My Answer to Julie’s Question

By Bryan Campbell

I came up with a response to Julie’s question (see “Fat Chance” page 4), but it requires a bit of introspection on my part. You see, I used to weigh 308 pounds.

I remember the day I got on the scale and saw that number. I have never been “skinny.” Ever since elementary school I was picked on as the “fat” kid. In high school, I was not obese, but I was certainly heavier than most of my friends. Much like Julie, I tried to make up for my physical problems with humor. I often made fun of myself.

But the climb from the high school 190 pounds (it sounds so glorious today, I can’t believe the lack of perspective I had!), to 308 pounds was a slow and steady one. I didn’t reach my full adult height of 6’3” until I was almost 21 years old. And from that point on, I gained a few pounds every year until that epiphany moment, 308.

My life changed when I was lucky enough to be working on a project with Bob Harper, trainer from The Biggest Loser. I asked him for advice and he told me, “If you really want my help, then I’m going to tell you what to do and what not to do as long as I am with you. If you won’t listen to me, then we’re done. If you ask me again to help you, I will.”

Bob wanted me to know what I was getting into before he agreed to help. That’s why he gave me that one last chance to back away.

If I asked again, he knew I was committed to changing my life.

And so I did. I never worked out with Bob, but I ate with him. He showed me in three or four meals the principles I would need to eat healthy for the rest of my life. He told me that I need to get in a minimum of 30 minutes of movement every day. After five days with Bob, I had lost 11 pounds!

Bob also shared with me a piece of advice that has kept his nutrition training in my head. He told me that it’s never too late to start, and that if you really want to make a change, start now. He told me that when people say that they are going to start on Monday morning, or that they are going to make a New Year’s Resolution, they are already making excuses.

I started eating better and going to the gym for 30 minutes during my lunch hour. After a while, my entire family was eating healthier. Now, my wife and I get up in the morning and spend an hour in the gym before work. It’s been a great bonding experience for us, and has helped to motivate me on days when I just don’t want to get out of bed.

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THEN

NOW Today I am 231 pounds. Not perfect, but at least it’s moving in the right direction. I am now running 3 days a week, and ran my first half-marathon on Thanksgiving Day, 2009. My current goal is to finish the National 15k Championship in under an hour and 30 minutes. You can monitor my training and see if I do it on my blog (http://bryansrunningjournal. wordpress.com). I’d love to hear about your progress too.

But if this is indeed the last time I have the chance to speak through words to you, I guess my answer to Julie’s question is fairly simple.

Start now.

Think about the next meal you are going to eat? What’s one thing you can do to make it healthier? How will you work 30 minutes of movement into your day?

Then, use the resources you have available to you. This magazine is a good start. You can find good nutritional and physical activity information in these pages. Talk to your friends. Let them know what you are about to start. I promise you, they would love to provide positive support for your efforts.

But most importantly, start now!

You will have moments of weakness. I can’t resist pizza (neither can Julie, see the online exclusive) and there are times when I break down and have three or four pieces. But once it’s over, I understand the amount of work it will take to make up for that pizza, and I commit to start my program again.

I hope that you are inspired by Julie, and that I have helped provide you some of the tools needed to make a change for the rest of your life. Now it’s up to you. P

Body Composition, Fat Distribution and Obesity: Impact in South Asians B y A n n a s wa m y R a j i , M D

Obesity is a growing problem all around the world. It is associated with many metabolic complications, including diabetes and heart disease. On a very simple level, body weight depends on the balance between number of calories consumed, stored and burned. Each of these is influenced by the person’s combination of genes, environment and behavioral components.

Health care providers all around the world use body mass index (BMI), which is an approximate measure of body fat in a person based on their height and weight. You can calculate your BMI by visiting the Power of Prevention Web site: http://www.powerofprevention.com/bmi.php According to World Health Organization, India will have the highest number of people with type 2 diabetes by the year 2025 AD (57 million), followed by China (38 million) and the USA (22 million). The greatest increase (195%) in the number of people with type 2 diabetes between 1995 and 2025 is expected to occur in India.

Researchers have shown higher rates of diabetes and heart disease in Asian Indians migrated from rural to urban India, and to developed countries like the USA and United Kingdom. We don’t have many studies that look at risk factors in rural and urban Asian Indians, or migrant Asian Indians in the USA A recent study found that a high number of Asian Indians in the USA have diabetes, prediabetes, and the metabolic syndrome.

South Asian Americans are the fastest growing immigrant group in the United States. Overweight (adults: 38% - 57%, children: 18% - 43%) and obesity (24%) rates in Asian Americans, especially South Asian Americans, are increasing.

Our group and others have compared Caucasians (non South Asians) to South Asians. South Asians have more fat around the middle and many risk markers for heart disease and diabetes. Body composition and where the fat lies play important roles in causing diabetes and heart disease. These important issues need to be considered in patients of South Asian ancestry. All these studies tell

us that looking at BMI alone in South Asians may not be enough to assess the risk factors for diabetes and heart disease.

It appears that the BMI cutoffs for obesity are different from that of Caucasians. Researchers are looking to define obesity cut points (BMI and waist circumference) in multiethnic populations to better assess and treat metabolic complications in non-European populations. For now the World Health Organization (WHO) suggests that obesity be diagnosed at a BMI of 27 in an Asian population.

The South Asian population in the USA is relatively young and very diverse. Therefore there is a need for early and culturally appropriate intervention. Education and lifestyle changes (nutrition and physical activity) are needed to prevent metabolic complications. http://www.ndep.nih.gov http://www.aapimsr.org/Diabetes/diabetesfacts.htm The bottom line is this. If you are Asian-American, you are at risk for metabolic complications at a lower BMI than a person of European ancestry. Get in to see your doctor at least on a yearly basis to document that you don’t have diabetes, high blood pressure, high cholesterol, or other risk factors for premature heart disease. And follow the suggestions in this issue of Power of Prevention® Magazine to keep your weight down. P Annaswamy Raji, MD, M.M.Sc, is the Director of Diabetes and Metabolism at Parkland Medical Center in Derry, NH, and Assistant Professor at Harvard Medical School, Boston, MA. She is Board certified in both internal medicine and endocrinology.

She obtained her fellowship in endocrinology at the Brigham & Women’s Hospital Boston, MA, and Masters in Medical Science from Harvard Medical School. Dr. Raji is a trained clinical endocrinologist and a clinical investigator with primary interest in clinical research in the areas of insulin resistance, diabetes and obesity and was the Director for program for weight management at the Brigham & Women’s Hospital until April 2009.

POWER OF PREVENTION • Vol. 1, Issue 3

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Battling C HI L D H O O D O B E S I T Y A Treatment Plan

By Naomi D. Neufeld, MD, FACE

C

hildhood obesity: the words have an ugly ring to them.

If you are an overweight child, or know one, you know how painful those words actually are, how they can sting and how bad they can make you feel. Every day in my pediatric endocrinology practice in Los Angeles, I see and treat children who are overweight. More often than not, the parent first will pull me aside and say “I don’t want him/her to know why he/she is here.” The truth is, the child probably already does know. He/ she has been teased in school, called names, left off of teams, left out of friendships, all because he/she is overweight.

While the emotional issues are real, childhood obesity has definite medical problems associated with it as well. If they are not treated early, these problems can affect a child for the rest of his or her life. The kinds of problems we see in overweight and obese children include: • Asthma • High blood pressure • Diabetes • High cholesterol • Abnormal, irregular or absent menstrual periods if they are girls • Girl-like breast development in boys • Bone malformation and hip fractures • Abnormally tall stature • Early development of puberty • Darkened skin around the neck and in the armpits, called acanthosis [ah-CAN-tho-sis] nigricans [NIGH-grih-cans] • Fatty liver

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So once they are in my office, what do I do?

First we need to know the causes of the child’s overweight.

The reasons our kids are obese or overweight stem from three simple facts: • Too much junk food and too few fruits, vegetables and dairy products • Too little physical activity • Too much screen time: TV, computer time, video games Too much junk food and too few fruits, vegetables and dairy products Not only are junk food and fast food widely available, but the marketing of fast food products is aimed directly at children.

And this marketing campaign is very sophisticated.

There are two other aspects of nutrition that have probably contributed to the obesity epidemic. The first is that people in general, and children in particular, are eating fewer fruits and vegetables, as well as inadequate amounts of whole grains. These foods are rich in nutrients and high in fiber, so they promote a sense of fullness and keep your digestive tract healthy.

The second food group missing from the meals of many overweight children is dairy products. I am continually surprised to see how many parents do not supervise their child in taking in three servings of milk or other dairy product per day. Milk is the best source of vitamin D, and we know from

many research studies that high vitamin D levels are associated with lower rates of insulin resistance and diabetes.

Too Little Physical Activity Children and adults are less physically active now than in previous generations. Children used to play outside of the home after school. Today many parents are fearful and say they are concerned about the lack of safe streets. There is also less physical education in schools due to financial constraints and to more (and, in many cases, misdirected) emphasis solely on academic subjects.

Too much screen time: TV, computer time, video games Time in front of the TV contributes to the development of childhood obesity because it slows down a person’s metabolic rate, the rate at which you burn calories when you just sit. If you are burning calories at 50 cal/hour while you watch TV, as opposed to 100 cal/hr when you move around, and you watch TV for 5 hours every day, you will hold on to 250 calories per day or 3500 calories every 2 weeks. Since there are 3500 calories in a pound of fat, by spending 5-6 hours/day every day in front of the TV you will gain 1 pound every 2 weeks. In a year you will gain over 25 lbs.

So, what do I do in my office when I see an overweight child?

First, my staff weighs and measures the overweight children, and I calculate their body mass index or BMI. What is your BMI? It is your weight divided by a multiple of your height.

The BMI provides a way of standardizing or comparing people of different heights. (You can find out more about BMIs and even calculate your own at the Power of Prevention Web site: www.powerofprevention.com/bmi/php). I plot my patient’s measurements on curves, which compare them to the rest of the population. I ask about their daily meals, physical activity, screen time, as well as any family history of diabetes, high blood pressure, early heat disease or stroke. On the physical exam I look at their blood pressure, teeth (how many baby teeth they have lost), skin for signs of acne or acanthosis nigricans, neck for signs of thyroid disease, lungs for signs of asthma, waist circumference, liver size and arm circumference. I often do blood tests to look for signs of insulin resistance, high cholesterol, high blood sugar (diabetes), liver disease or thyroid disease.

I base my treatment on how severely overweight the child is (how much their BMI differs from normal) and what other signs of disease they have.

In my practice I have access to a family-based weight management program called KidShape. This is a 9-week program involving families of children who are obese, as defined by BMI above the 95th percentile for age and sex. During these 9 weeks families meet in groups with a dietitian, a physical activity instructor, and a mental health professional to deal with topics related to eating healthier and being more physically fit, as well as feeling better about themselves. KidShape has been around since 1986 and is available throughout the country. More information can be found at the Web site www.Kidshape.com.

Treatment Plan The table below lists the steps that I take with my patients above the age of 5 years and below 19 years, based on the severity of their weight.

BMI > 85th percentile but < 95th percentile for age and sex 1. Lab tests 2. Limit TV to 1 hour per day 3. Add physical activity, as noted below 4. Add fiber to the meal plan, using the USDA Table Fiber Content of foods.

(Check their Web site: http://library.umsmed.edu/pe-db/pe-fiber-food.pdf).

Fiber requirement is calculated as (age in years + 5 grams per day) 5. Dietitian assessment 6. Monthly office visits 7. Physical activity: pedometer, to reach 6,000 to 10,000 steps per day BMI > 95th percentile, but < 3 Standard Deviations (SD) [SD shows how much variation there is from the “average”] above the mean for age and sex 1. KidShape classes or comparable family-based pediatric weight management program 2. Lab tests 3. Low-calorie diet (1200-1500 kcal/day) 4. Dietitian consultation 5. Weekly office visits 6. Physical activity: pedometer, to reach 6,000 to 10,000 steps per day; physical activity videos or classes 7. Monthly laboratory tests 8. If liver enzymes are abnormal, I add vitamin E 200 IU per day.

Vitamin E has been shown to reverse liver damage, presumably by protecting the liver from oxidative damage 9. If vitamin D Levels are below 30, I add 50,000 IU of vitamin D per week 10. If insulin is high, I may consider the medication metformin BMI >3 SD above the mean 1. KidShape classes or comparable family-based pediatric weight management program, more than 1 series to reach goal weight 2. Lab tests 3. Repeat insulin, other labs in 1 month 4. Restricted calorie meal plan: 1200, 1500 or 1800 kcal/day 5. Dietitian consult 6. Weekly office visits 7. Physical activity: pedometer, to reach 6,000 to 10,000 steps per day; physical activity videos or classes 8. Monthly laboratory tests 9. If liver enzymes are abnormal, I add vitamin E 200 IU per day 10. If vitamin D Levels are below 30 ng/ml, I add 50,000 IU of vitamin D per week 11. May consider the medication metformin if insulin is high 12. For patients above the age of 12, some physicians have recommended sibutramine, an appetite suppressant which has been approved by the FDA for use in children 13 years and older. Patients who take this medication require monitoring of blood pressure and heart rate.

Medications often used in the treatment of adults or teens have not been approved or found safe for younger children. Until these drugs have been approved for children, they cannot be recommended. There are no quick fixes in the treatment of obesity, and especially in the case of children. Our focus for children should be on their health, not so much their weight.

Naomi D. Neufeld, MD, FACE, is the President of Neufeld Medical Group (founded in 1996) in Los Angeles. Her practice focuses on the problems of growth, obesity, diabetes and the hormonal problems that can affect children and youth from birth to 21 years. Dr. Neufeld is Board Certified in both Pediatrics and Pediatric Endocrinology by the American Board of Pediatrics. She is the founder and President of KidShape®, Inc., a family-based pediatric weight management program, which has been in continuous operation since 1986 and now operates sites in Los Angeles, Ventura and Orange Counties.

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What is Power of Prevention doing in SCHOOLS? B y R . M a ck H a r r e l l , M D , F A C P, F A C E

The Power of Prevention School Outreach Program was started

by Dr. Donald Bergman, past President of the American Association of Endocrinologists (AACE). The program is designed to teach children in the 5th, 6th and 7th grades about the benefits of healthy eating and daily physical activity. The idea originally was to get health professionals (endocrinologists, primary care physicians, nurses and health educators) into our middle schools to help teachers make an impact on the problems of childhood obesity and diabetes. Now anyone can get involved.

The materials to bring these healthy messages to schools are available for download at http://www.powerofprevention.com/ download_all.php. In particular, AACE intends for the Power of Prevention School Outreach Program to target ethnic minority schools, where the risk for diabetes is higher and where preventive measures are more likely to make a difference.

As a practicing Endocrinologist in South Florida, I was recently able to lead a Power of Prevention program at the Lauderhill Middle School in Fort Lauderdale. I hope that my experience may be informative for anyone with an interest in prevention programs for children. I was able to arrange our program through the Lauderhill Health Clinic, which is run by Broward Health, my employer. The Lauderhill Clinic sits on the property of Lauderhill Middle School, 100 yards from the school’s back door. Through my contacts at the Health Clinic, I was able to obtain a security pass to spend 2 hours in Lauderhill Middle with nurse Adi Kogler and Broward Health administrator Lori Kessler.

Our first appointment was with Mrs. Mary Diggs’ morning health class. The class had 35 Hispanic and African American middle schoolers from Fort Lauderdale. When I asked if anybody in the class had a relative with diabetes, nearly every hand went up. Most students had seen family members give insulin and prick their fingers to measure blood sugar. In short, the diabetes epidemic had already struck the families of students at Lauderhill Middle School.

R. Mack Harrell, MD, FACP, FACE, graduated with Phi Beta Kappa and AOA honors from the University of North Carolina at Chapel Hill. He completed a three-year residency in Internal Medicine at the University of Minnesota, followed by a clinical and research fellowship in Endocrinology at Duke University. He was recruited by the Cleveland Clinic Florida in 1991 and became their first Chief of Endocrinology. In 1999, Dr. Harrell became the Director of Metabolic Outcomes for the North Broward Hospital District in Fort Lauderdale where he has practiced endocrinology for the past 10 years and is the acting Medical Director for the North Broward Diabetes Center.

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The students were bright and happy to learn. Mrs. Diggs made sure that classroom behavior was carefully controlled. After the nutrition and physical activity slide show was completed, I had the students stand and dance to my rap tune “Get Fit (see lyrics on page 24).” This desk-side movement was well-received and is an example of how kids can be active even when they are indoors.

Later in the morning, we did a second program in the school’s media center. The attendance at the second program was much larger with more than 150 students and teachers. I noticed that one of the students from Mrs. Diggs’ class had returned for a second look at the presentation after lunch. So, I decided to test him. I asked him what he had eaten for lunch. He smiled and said: “Pepperoni pizza and chocolate milk!” At this point, I realized that this prevention program might be a lot tougher than I had realized. The library session was tough because of trying to keep the large number of students focused.

In summary, I believe that there is a real need for endocrinology doctors, nurses, and health educators to bring the diabetes and obesity prevention message to our middle schools. But this message should be delivered in the larger context of school reform. Without schools that offer physical education on a daily basis and healthy food choices for lunch, all the slide shows and well-intentioned rap tunes in the world will not change student behavior. The time has come for American educators to practice what we preach and to “show” instead of just “telling.”

The Power of Prevention is about changing human behavior. We need to enlist politicians, school administrators and parents to help health professionals get the prevention message to our children. If you are a parent with obesity or diabetes, you are able to reach out to children better than anyone else. Go back to school and teach kids that these are preventable diseases. If you have a school in mind or new ideas regarding the development of a program in your community, don’t hesitate to contact the Power of Prevention at http://www.powerofprevention.com/contact.php. P

Schools Can Help with Childhood Obesity Resources to Promoting Health at Home and at School

B y B e ck y G o n z Á l e z - C a m p o y

www.healthiergeneration.org – Click on Healthy School Programs to find the Healthy School Builder or click on any of the parent resources

The message is simple. Eat more fruits and vegetables. Control portion size. Move your body regularly and often. Follow these steps and you reduce the risk of obesity and its complications.

So why are today’s children more likely to die at a younger age than their parents? They haven’t been getting the message. Not at home. Not at school. Not in the media.

In theory, the solution is also simple. Teach children and their families about how to live healthy lifestyles and motivate them to apply what they learn. The key is to involve kids in the process both at home and at school. Here’s how.

Start by modeling healthy behavior yourself. Take kids shopping for groceries. Have them select food for your family. Teach them how to read nutrition labels. Introduce them to many tastes and textures. Make time to be physically active together. Encourage your kids to choose activities they can do all of their lives.

Get involved with promoting healthy living at your child’s school. The Child Nutrition and WIC [Women, Infants, and Children] Reauthorization Act of 2004 requires all school districts that receive federal funding from the school lunch program to have a wellness policy in place. The purpose of this policy is to ensure that school environments promote and protect students’ health, well-being, and ability to learn by supporting healthy eating and physical activity.

It’s also designed to promote employee wellness to improve productivity and reduce rising healthcare costs.

I am a parent of three children ages 22, 19, and 16. I am also a former school board member from a suburban district in Minnesota. I am currently helping this school district to get its Wellness Policy up and running. Most schools should have a Wellness Advisory Committee that oversees activities to promote and sustain wellness for students and staff. This group provides a valuable opportunity for collaboration among parents, teachers, administrators, community members and students to develop effective methods for promoting wellness.

Becky González-Campoy is Chief Operating Officer of the Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME), PA and Executive Director of MNCOME Foundation.

Becky holds a Bachelor of Arts degree from Macalester College (1983), St. Paul. She’s a Past President of the Minnesota Medical Association Alliance and is a former member of the Board of Education for Independent School District 197 (West St. Paul/Mendota Heights). She currently is working with the school district to implement its Wellness Policy.

www.actionforhealthykids.org – Provides ideas that work from around the country www.powerofprevention.com – Interactive games and educational tools developed by the American Association of Clinical Endocrinologists www.bethecatalyst.org – A Minnesota-based youth leadership group dedicated to promoting healthy living advocacy

Before our Wellness Committee could plan its strategy for improving health, each school had to determine its strengths and weaknesses. We used an online assessment tool called the Healthy School Builder (see box) to collect baseline data about our school’s breakfast/lunch programs, health and physical education curriculum, and current wellness practices, among other things.

This information helped each school create an individualized plan to meet the gold standard set forth by the Healthy School Builder.

Ongoing communication is an essential part of any strategic plan to bring about change. Knowing we have several audiences we must educate and motivate, we use several avenues to deliver wellness information and resources:

• Posters and parent newsletters. The district’s wellness liaison collects and distributes posters and healthy living tips via e-mail to key staff at each school. Fruits and vegetables might be featured one month; how to beat stress might be featured another month. Teachers can display the posters in classrooms or common areas. Principals can include the healthy living tips in their newsletters to families.

• District Web site. The district Web site provides a wellness home page with links to each school’s wellness page. We created a name for this link that started with a letter near the beginning of the alphabet so visitors would be sure to see it – Center for Wellness. Here parents and staff can learn about the latest wellness activities at each school and find resources to help them lead healthier lifestyles.

• School-wide announcements. Principals and students deliver healthy living tips during daily announcements.

Among the most valuable contributions Wellness Advisory Committee members provide is feedback regarding how effective the current activities are and how we can improve the program.

I pushed hard to include secondary students on our committee for two reasons: First, almost no resources for reaching secondary students exist – most youth wellness programs are geared toward children in pre-school through 6th grade. Second, students know best how to reach their peers.

The students on our Wellness Committee provide the adult members with a reality check. School announcements at the high Continued on page 26

POWER OF PREVENTION • Vol. 1, Issue 3

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By R. Mack Harrell, MD So I’m in the 6th grade, 7th grade, 8th grade Sit tin’ in a classroom all day long When you gimme a chance, I wanna dance Look out world, I’m gonna be st rong.

And I will, I will…GET FIT I will, I will…GET FIT I’m not e atin’ Twinkie s, sucking down sof t drinks Buyin’ junk food… ‘cause it’s just not cool No Fruit Loops, gimme veggie s and f ruits Feed my brain so I’m re ady for school.

I I I I

will, I will…GET FIT will, I will…GET FIT will, I will…GET FIT will…GET FIT!!!

Lyrics to be sung to the tune of “We Will Rock You”

Start

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Food Pyramid

What you should EAT EACH DAY!

THEME: STAYING HEALTHY!

Grains: 6 ounces (oz.)

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Choose low-fat or lean meats and chicken. Eat more fish, beans, peas, nuts and seeds.

P U F

Oils: Limited

Include whole-grain bread, cereal, pasta, rice or crackers.

Veggies: 2.5 cups

Eat more dark green types like broccoli and spinach and orange types like carrots and sweetpotatoes.

Fruits: 2 cups

Eat a wide variety. Choose fresh, frozen, canned or dried fruit.

Milk: 3 cups

Choose low-fat or fat-free Limit your intake of fats, milk, yogurt and other dairy especially solid fats like products. butter, stick margarine, shortening and lard.

For more info go to www.mypyramid.gov

Balance Energy Exercise Fruits

Nutrition Portions Protein Sports

Vegetables Weight

SEKBABTLAL SALBEABL RCSOCE

OFLLABOT

IGISNMWM NSITNE

IBOROCLC NAANAB

RARSTCO GEOARN

PCAHISN PELPA

Portion Facts • Three ounces of cooked meat, fish or poultry is the size of a deck of cards.

• One egg or a tablespoon of peanut butter is one ounce.

• A slice of bread or a half cup of rice or pasta is one ounce.

• A medium bagel is the size of a hockey puck.

• One ounce of cheese is the size of four dice.

• A small baked potato is the size of a computer mouse.

25 POWER OF PREVENTION • Vol. 1, Issue 3

ANSWERS: Basketball, Football, Baseball, Swimming, Soccer, Tennis, Broccoli, Banana, Carrots, Orange, Spinach, Apple

Continued from page 23

school? No one listens to them. Abundant healthy options at lunch? Not so much. We need vegetarian options. We need intra-mural sports opportunities.

Reach us through media we actually use. Their input prompted a student survey of lunch menu options and suggestions for improvement. Student feedback also led us to consider other venues to deliver the healthy lifestyle message. Students spend time on Facebook, not the district Web site. They use text messages regularly. We’re now exploring the use of Twitter to send quick healthy living messages to students and others who spend time on their cell phones or on the Internet.

We’re also learning the value of working with other schools and health agencies. Five districts in northern Dakota County, Minnesota, are working together with the Dakota County Public Health Department on a 5-year grant to promote eating more fruits and vegetables at school and at home. Through this alliance, we connected with Catalyst, a group that helps students lead the way to improving health among their peers.

We invited Catalyst members to work with students at our high school, to help us prepare our strategic plan to boost the consumption of fruits and vegetables. The group is working on a student-oriented video that schools can run on monitors mounted in their hallways and cafeterias. The students will develop a healthy living mentoring program for elementary students as well.

We’ve replaced soda with water in the vending machines. No more supersized bottles of Mountain Dew. Our lunches include more salads, fruits, baked foods instead of fried foods, and smaller portions. No more sugary drinks and donuts to start the day for students.

Our toughest sell? Getting the adults to improve their nutrition and increase their physical activity. Again, feedback from Wellness Committee members proved to be very valuable. Principals serving on the Committee pointed out that teachers are more likely to listen to their peers rather than to district administrators. So our approach is similar with staff as it is with students – encourage teachers with a passion for healthy living to inspire others through example. We encourage anyone with a great idea to run with it. As a result, we are seeing the start-up of special interest groups, such as walking clubs and yoga classes.

Incorporating health promotion in schools requires teachers to understand its importance. Teachers are often overloaded with other demands. Here, we focus on research that links good health to solid student performance. Healthy kids are better able to learn than those who are poorly nourished and sedentary.

Our efforts to promote wellness extend to school fundraisers and concessions at athletic events. We are slowly replacing candy sales with wrapping paper, plants, school spirit wear, and other options. The challenge is to convince those whose programs depend on these sales that these alternatives make as much money. Granola bars, fruit, and water are making their way onto the menus of the concession stands.

Call your school to find out what your district is doing to promote healthy living and ask how you can join the effort. It’s that simple. P

26

POWER OF PREVENTION • Vol. 1, Issue 3

Letters

from Readers Question: I saw a copy of Power of Prevention® Magazine in my endocrinologist’s office. I found it very informative, brief and to the point, easy to read AND to understand. How can I subscribe to this magazine? I believe my whole family would benefit from this magazine!

Answer: It’s very easy to subscribe to the magazine. Simply e-mail subscribe@powerofprevention.com or call (904) 353-7878. Be sure to include your full name and address in all correspondence.

Question: What kinds of topics does Power of Prevention® Magazine discuss?

Answer: Endocrinology is a field that covers a variety of conditions related to numerous glands and hormones in the body. Therefore, each issue of Power of Prevention® Magazine focuses on a different endocrine disorder – thyroid dysfunction, diabetes, and obesity to name a few.

Question: How can I find an endocrinologist in my area?

Answer: It’s easy! Just visit www.aace.com and click on resources and go to “Find an Endocrinologist.” This tool will allow you to search for an endocrinologist by location (either City/State or ZIP code) and/or by specialty.

Question: How can I get involved in Power of Prevention?

Answer: There are a lot of ways that you can get involved. One way – share your story with us by sending an e-mail to feedback@powerofprevention.com.

Visit www.powerofprevention.com for more information!

O N L I N E

E X C L U S I V E s

How the Brain Controls Your Weight

By Tiffany Beckman, MD, MPH and J. Michael Gonzalez- Campoy, MD, PhD, FACE

O

besity is a disease that is partly genetic, but mostly due to the world we live in. Our ancestors had to work to get food.

Today you can take a drive, roll down the car window, and have 2,000 calories of good-tasting food dumped onto your lap, all for under $5.00, and in less than 5 minutes. Then you can spend the day in an office chair, clicking away at a computer. And at the end of the day you go home to watch TV. You never use the calories you ingest, and you gain weight.

Appetite is a highly regulated process. Although feeding is a behavior, most of the feeding we do is driven by our brain – there is biology involved. We can exert conscious control and overcome the powerful hunger and fullness signals in the brain. But most of the time the biology takes over. As an example, we may “learn” to eat at certain times. When the clock strikes noon, we might all say, “let’s go to lunch,” when in fact, we are not really hungry. We have programmed ourselves to eat at noon because it is lunch time. People eat in many other social situations when they are not hungry. Clearly we do not eat just to meet our energy needs. Instead, we eat out of circumstance, pleasure, or reward. Feeding behaviors may also be related to our emotions. These eating habits start with stressful times, and then become routine.

This discussion will focus on the brain and how it controls our feeding. This is a very complex subject, but we will give you an overview. We will highlight some of the hormone and nerve pathways that regulate food intake and body-fat mass. This discussion is a very simple overview. It is aimed to provide you with a brief introduction to the subject.

As an enrolled member of the Leech Lake Band of Ojibwe/Minnesota Chippewa Tribe, Tiffany R. Beckman, MD, MPH, is believed to be the first American Indian adult Endocrinologist in the nation. She was born, raised, and trained in Minnesota. Dr. Beckman is currently an Assistant Professor of Medicine in the Division of Diabetes, Endocrinology, and Metabolism at the University of Minnesota. Dr. Beckman is board certified in Endocrinology, Diabetes, and Metabolism and Internal Medicine. She is a Research Associate at the Department of Veterans Affairs Medical Center in Minneapolis. Dr. Beckman serves as a Clinical Endocrinology Consultant for Indian tribes throughout Minnesota. Her primary research interests are the neurobiology of obesity and diabetes prevention in high-risk populations.

J. Michael González-Campoy, MD, PhD, FACE, is Medical Director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME). He earned his MD and PhD from Mayo Medical School and Mayo Graduate School of Medicine in 1991. He is board certified in Endocrinology, Diabetes and Metabolism. Dr. Gonzalez-Campoy is a recognized national expert on diabetes and obesity and a proponent of adiposopathy as a treatment target.

Dr. Gonzalez-Campoy is Clinical Assistant Professor of Medicine at the University of Minnesota.

Overview Our evolutionary survival has depended upon our ability to get and store calories. The brain tells you if you are hungry or full. Literally, the brain needs a lot of input before it can make up its mind. Although the brain’s role in balancing energy and fat stores is very complex, there are some simple concepts worth knowing about.

What does the brain see?

There are two types of signals the brain gets from the rest of the body: those that make us hungry and lead us to eat, and those that make us feel full and tell us to stop eating. How does the brain handle all these signals? The brain is made up of nerve cells called neurons. Neurons use chemicals called neurotransmitters to send signals to each other. Neurons control all biological functions in the body. The neurotransmitters that they make, and the connections that they have, define the function of each nerve cell.

The nerve cells in the hypothalamus and hindbrain that regulate feeding have special neurotransmitters. These neurotransmitters regulate food intake by either making you feel hungry or full. The bottom line is this. The brain gets all kinds of information. The information results in the activation of neurons. The neurons that work more at any given time determine if you feel hungry or full.

Look who’s talking Technically, the brain isn’t the only organ that regulates appetite. It gets plenty of help from the rest of the body. Fat cells, the stomach, gut, and pancreas all send signals to the brain.

Let’s take a look at an example. Fat cells produce leptin, which halts your appetite. And ghrelin is a hormone made in the stomach that makes you hungry. The level of ghrelin is highest right before our next meal. An interesting fact is that ghrelin levels decrease after gastric bypass (weight loss) surgery, which contributes to its success. The brain can tell how much leptin and how much ghrelin are present at any given point in time. After sorting this information, the brain tells you if you are hungry or full.

There are hundreds of other signals that are constantly sorted by the brain. So there is tremendous biology behind the simple act of feeding!

Putting it all together The appetite network receives changing signals depending on the energy state of the body. Usually, signals that cause you to eat also keep you from using energy. And signals that make you feel full make you use energy. Take for example what happens in obesity. Because there is excess fat mass, the leptin levels are elevated. The high leptin levels signal the brain that there is a positive energy balance. Yet, the

O N L I N E

E X C L U S I V E s

Continued

leptin signal that you are full can be overcome by the more powerful ghrelin signal. Ghrelin stimulates neurons in the brain which lead to hunger and feeding. In other words, Ghrelin tells the brain to eat, even though there is a lot of leptin from fat cells.

Unfortunately, in people with obesity, most eating patterns do not match actual energy needs. Certain parts of the brain that provide pleasure are stronger than the control mechanisms that make us feel full. This is why most people who eat too much just can’t help themselves. Once these bad feeding patterns start, it is easier for them to keep happening. On the other hand, there are fewer signals to starve.

Our bodies evolved to get and store calories. The appetite network is designed to protect the body, and to help us grow, develop, and have a long life. External factors like an excess of calories in our environment, affect our feeding choices. The delicate nutritional balance required for health is altered, and the result is obesity.

Take Home Message Feeding is a behavior. But feeding is under very complex biological control. Doctors are continuing to learn more about the brain and how it regulates our energy balance and fat stores. This in turn helps us to understand what causes weight gain. In time, the brain will teach us how best to treat obesity. P

A DAY WITH

JULIE B y B r y a n C a m pb e l l

When I talked to Julie and Mike Hadden about being interviewed for this issue of Power of Prevention® Magazine, I said that I wanted to spend a day in the life of Julie. I wanted to see her normal physical activity routine, her interactions with her family, and most importantly what she ate!

Julie and Mike are wonderful people, and they agreed to the interview on one condition. They both knew that I had lost a lot of weight in the past year, and they said that if I wanted to report on Julie’s Boot Camp workout, I would have to participate in it!

So, while the idea of being a journalist in a early morning Boot Camp workout was not my planned daily workout, I gladly signed up for the sake of the interview.

All I can say about the workout that morning was that it was the hardest thing I have ever done in my life. The trainer, Margie, calls the program “The Accumulator.” I have provided a complete breakdown of the routine (continue reading the Online Exclusives section for the complete breakdown) for your review. But the general summary is that we ran 1/8th of a mile, then performed an upper body exercise, then ran another 1/8th mile, then did two exercises. This pattern repeated until we had performed a total of 10 repetitions of the set.

After this painful experience (I was still sore 4 days later) we went to Julie’s home where she planned to make lunch for her family and me.

Having read Julie’s book, I should have known what we were having.

“It’s not a secret that I am addicted to pizza,” giggled Julie. “Any shape, any form, whatever. And so I just couldn’t give it up.”

Julie made pita pizzas (continue reading the Online Exclusives section for the recipe), a healthy alternative to a regular pizza. The recipe includes ½ pita loaf for a crust, low-fat cheese, and virtually any toppings you want. For pepperoni she used turkey pepperoni. And she loaded them up with delicious vegetables.

“It’s healthy and it’s easy and it’s a great way to get pizza, and it’s a lot cheaper than ordering out,” Julie said. “And I love it because you can make as much or as little as you want and it’s not just sitting around.”

In case you are wondering, the pizzas were delicious. I ate two by myself (I figured the morning workout earned me the right!). But as we ate, Julie talked about all of the other delicious low-calorie recipes she has discovered since she came home from the show. Many of them are available in her book, Fat Chance: Losing the Weight, Gaining my Worth, available at amazon.com. P

O N L I N E

E X C L U S I V E s

The Accumulator I

t starts with one exercise and ends with 10. A 60-second run is placed between each set.

Start with the first exercise and add the next after each 60-second run.

10 push-ups 100 meter Run 10 push-ups 20 mountain climbers* 100 meter Run

*Mountain Climbers • Place yourself in the basic push-up position with your arms in line with your chest and your legs extended outward.

• Rest on the balls of your feet while bringing one leg (for this example we'll say left leg) forward to your chest and back to its original position. Keep the right leg tucked during the forward and back movement of the left leg.

• Repeat the motion described in Step 4 rapidly, alternating one leg forward and one leg back. This movement mimics the "climbing of a mountain."

10 push-ups 20 mountain climbers* 10 squat thrusts* 100 meter Run

*Squat Thrusts

10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks

• From a standing "parade rest" position, drop to a squat position with your hands on the ground near your feet.

100 meter Run

• Throw the feet back, putting yourself into a push up position.

10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks* 10 Burpees

• Again pull the feet forward to a squat position with hands on the floor.

• Stand again in a parade rest position.

100 meter Run 10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks* 10 Burpees, 10 knee tuck Jumps 100 meter Run 10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks* 10 Burpees, 10 knee tuck Jumps, 10 *Tricep Russian Kicks

*Up/Down Planks • From a push up position, bring one knee to the elbow • Stabilize body then return leg to extended position • Alternate with other side

100 meter Run

*Burpees:

10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks* 10 Burpees* 10 knee tuck Jumps* 10 Tricep Russian Kicks* 10 plyo scissor lunges

• Begin in a squat position with your hands on the floor in front of you.

100 meter Run 10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks* 10 Burpees, 10 knee tuck Jumps, 10 Tricep Russian Kicks* 10 plyo scissor lunges* 10 jump squats

• Kick your feet back, while simultaneously lowering yourself into a pushup • Immediately return your feet to the squat position, while simultaneously pushing up with your arms.

• Leap up as high as possible from the squat position.

100 meter Run

*Knee Tuck Jumps

10 push-ups 20 mountain climbers* 10 squat thrusts* 20 Up down planks* 10 Burpees, 10 knee tuck Jumps* 10 Tricep Russian Kicks* 10 plyo scissor lunges* 10 jump squats* 20 twisting planks.

• Start in a standing position

100 meter Run

• Jump as high as you can, while lifting both knees together toward your chest • Bring arms “under” knees in the air to form a tuck position

O N L I N E

E X C L U S I V E s

Pita Piz z a s

Serves 2

Ingredients * Tricep Russian Kicks • From a sitting position, place arms directly beneath shoulders and lift buttocks the ground so you are supported by arms and feet.

• Kick out one leg in front of you, supporting your body with one leg and two arms • Switch legs by bringing the extended leg down for support, simultaneously kicking the support leg out front.

• Repeat

1 whole-wheat pita Nonstick baking spray 3 Tbsp tomato sauce ½ tsp sriracha Asian chili sauce (optional) ¼ tsp honey ½ cup low-fat grated Italian cheese blend Turkey pepperoni, if desired 2 Tbsp fresh, chopped basil Crushed chili pepper (optional)

Directions *Plyo Scissor Lunges • Stand with your feet hip-width apart, hands clasped behind your head.

• Lunge forward with your left foot and lower yourself until your right knee almost touches the floor • Explosively push up and scissor your legs in midair, landing with your right leg forward • When you land, drop down, explode up, and scissor again.

*Jump Squats • Start in a squat position, knees bent and thighs parallel to the floor.

• Jump up as high as you can toward the ceiling, and throw your hands up as though you are going to touch the ceiling.

*Planking Twist

Preheat oven to 400°F. Separate the top from the bottom of the pita to create two equal circles. Place both circles on a baking sheet sprayed with nonstick baking spray (smooth side down). Combine the tomato sauce, sriracha and sugar for a spicy sweet sauce.

Spread the tomato mixture on the pitas and top with the Italian cheese blend and pepperoni.

Place in oven and bake for 10 minutes, or until cheese is melted and crust is toasted. Top with fresh basil and chili pepper if desired.

Per-Serving Nutritional Information (with sriracha, ½ cup turkey pepperoni and chili pepper)

• Get into a full plank position

132 calories

• Now bring your right knee across your chest. Hold there for 2 counts, then swing your right leg back and up to the ceiling, raising your hips while lowering your shoulders down toward the floor.

3.9g total fat (1.8g saturated fat)

Then, switch sides bringing your left knee across your chest. Hold for 2 counts and then send your left leg toward the ceiling, raising your hips while lowering your shoulders down toward the floor. P

25mg cholesterol 633.5mg sodium 15 total carbohydrates (1.7g fiber; 2.3g sugar) 8.7g protein

DearFriends, Friends, Dear Dear Friends, Dear DearFriends, Friends,

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In public no less!

As important, I no longer with the dolphins.

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Visit weighyouroptions.com/pop Visit weighyouroptions.com/pop to view Joan’s video message. toto view Joan’s video message. view Joan’s video message. ©2009 Allergan, Inc., Irvine, 92612. rights reserved. ©2009 Allergan, Inc., Irvine, CACA 92612.

AllAll rights reserved. ©2009 Allergan, Inc., Irvine, CA 92612. All rights reserved. ©2009 Allergan, Inc., Irvine, CACA 92612.

AllAll rights reserved. ©2009 Allergan, Inc., Irvine, 92612.

27 POWER OF PREVENTION • Vol. 1, rights Issue 3reserved.

Special Thanks to

The American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) would like to thank Allergan, Inc. for its support of patient-focused initiatives on obesity.